AUGUSTA, Maine — Much of the talk about the recertification of Riverview Psychiatric Center by the federal Centers for Medicaid and Medicare Services focuses on the $20 million in annual federal funding that hinges on it, but advocates for mentally ill Mainers and the Department of Health and Human Services say far more is at stake than just money.

The state-run hospital in Augusta lost its CMS certification last September. State officials have been trying to reverse that ruling ever since, as they also strive to abide by the state’s 1990 AMHI Consent Decree, the overseer of which says he’ll do his next review in October.

Not only is future funding at risk, but CMS has indicated that it could one day demand a refund of federal dollars that have flowed into Maine since the decertification.

Another failure would have financial ramifications for years, but for mental health advocates, the real problem would be a loss of oversight.

Jenna Mehnert, executive director of National Alliance on Mental Illness-Maine, said she considers CMS’s regulations to be the minimum requirements for running a psychiatric hospital and the state’s inability to meet them would be terrible in terms of maintaining patient and staff safety.

“This is the floor under which no one’s services should drop,” said Mehnert. “The challenge around Riverview is that these are basic standards. They’re not aspirational standards. … It’s scary to think that one of the state’s biggest mental hospitals can’t meet them.”

Aside from what accrediting organizations think, Riverview and other aspects of Maine’s mental health system are subject to a rigorous set of standards established in a document called the AMHI Consent Decree. The document resulted from a 1990 class-action lawsuit brought on behalf of former Augusta Mental Health Institute patients after poor conditions and overcrowding led to the death of several patients.

In the wake of the closure of AMHI, the document required the state to establish and maintain a comprehensive mental health system. Former Maine Supreme Court Chief Justice Daniel Wathen is the courtmaster for the consent decree, which means he is in charge of ensuring that the standards established by the decree are upheld.

Wathen said that though the loss of CMS funding would be problematic, the actual standards demanded by CMS are covered by other state and federal regulations — including the consent decree.

“Any time there’s some question about the people in institutions being deprived of their constitutional rights, which in the case of mental health is the constitutional right to treatment in the least restrictive setting, the Justice Department can step in,” Wathen said. “If CMS was not there, the hospital would be under virtually the same regulatory scheme by at least two or three other regulators. … I think the real significance of CMS certification is the funding.”

As part of his courtmaster duties, Wathen periodically audits Riverview, as well as the mental health care provider system in the wider community, to ensure compliance. Wathen said his next review of Riverview will take place in early October, which would be after the state’s hoped-for timeline for CMS recertification.

“I’m going to take a more detailed look at the operation of the hospital, see what they’ve accomplished at that point and make a report at that time to the court on how well they’ve recovered from what was admittedly a bad situation,” Wathen said. “If I conclude that there is something they’re doing that they should not be doing, the consent decree gives me the opportunity to make a recommendation and [DHHS] either has to accept and put the recommendation into place or they have to challenge it and go to court almost immediately.”

In that instance, a court could order the state to spend more to meet the terms of the consent decree, regardless of availability of federal funding.

For Health and Human Services Commissioner Mary Mayhew, there’s irony in the concept of losing the very funding that is so important to providing the best care possible for some of the state’s most mentally ill patients.

“Riverview wants to be a center of excellence that provides high-quality psychiatric services,” said Mayhew. “That’s what we need to be most focused on.”

She said part of the difficulties with CMS certification is borne from Riverview’s specialized role as a long-term psychiatric care facility whose patients stay long beyond what is typical in most private hospitals. Riverview cares for both civilian clients who need to be institutionalized for long periods of time as well as individuals referred from the criminal justice system who have been found not criminally responsible for violent crimes and others who need court-ordered psychiatric evaluations.

Linked to the federal funding is an extensive set of federal regulations, which is where the state went awry. An unannounced survey visit by CMS personnel last year found numerous violations of those regulations — including the use of restraints and tasers on patients.

Mayhew and others say those problems have been corrected. She said the state has re-applied for recertification and she’s hopeful that CMS will perform another unannounced survey by the end of September.

The remaining outstanding issues that were previously identified by CMS involve documentation of clinical treatment plans that by themselves would probably not lead to decertification, according to Mayhew.

Mehnert said the potential funding problem at Riverview exacerbates problems with an already underfunded mental health system. But she said many of the problems at Riverview are caused by a small number of high-needs patients who might be best served elsewhere.

“They are very physically aggressive and don’t have behavioral management tools,” said Mehnert. “What they need is a small, specialized hospital or we as a state need an agreement with one of those in another state.”

Mayhew said despite past problems, Riverview is still providing quality care and that another accrediting agency known as the Joint Commission gave the hospital its “Gold Seal of Approval” for safety and quality of care in March. The nonprofit organization, which is recognized nationally for its assessments of health care providers, uses similar standards as does CMS, said Mayhew.

Mayhew said she welcomes oversight but maintains that Riverview was unfairly decertified. The state is in the process of mounting a legal challenge to ensure future funding and to guard against being asked to refund any money to the federal government for money that is flowing to Maine under decertification.

“No matter what, our focus is on ensuring that we have the best possible model at that hospital,” said Mayhew. “That means meeting our objectives around quality care and patient and staff safety, because Riverview is such a significant part of the mental health system in Maine.”